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a <br /> 1 • SEWAGR <br /> Distance to Public Sewers Connection necessary: Yes No% <br /> Does existing septic system comply with Ord . $1549 : Yeses No_ <br /> Unknown If no, explain: <br /> Describe septic installation tob installed: � ���F �� <br /> r <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes-2L No State clef ieieney : t <br /> Does existing or porposed use make this well public water: Yes <br /> No Xi Sample of well water taken: Yes No .! Date aken <br /> Results ' Additional information or clommenis4,E <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . =,_ MOSQUITO QRy ^,TO) PSfLNTIA,1.L <br /> State possible vector potentiFtl & necessary control: <br /> 5 . TOTLET/BATH FACILITES <br /> No . & location existing : Additional <br /> facilities needed _ <br /> 6 . PREV IO172 OPERATION HIST= , <br /> 7 . GENERAL SAiU'r,A'1'ION <br /> State any problems riot previously noted- <br /> 8 . FQPULATION DFNSTIX <br /> A p p x. No . People per o T"Ji . <br />